Mersey Care NHS Foundation Trust - Home - …...2017/12/08 · and wellbeing of Trust Service users and staff. All NHS sites will be smoke free healthcare settings the Trust has agreed

SA20 Nicotine Management Policy – Version 10 – November 2017

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TRUST-WIDE CLINICAL POLICY DOCUMENT

NICOTINE MANAGEMENT POLICY

Policy Number: SA20

Scope of this Document: All Staff

Recommending Committee: Smoke Free Strategy Group

Approving Committee: Executive Committee

Date Ratified: September 2017

Next Review Date (by): September 2018

Version Number: 2017 – Version 10

Lead Executive Director: Executive Director of Nursing

Lead Author(s): Modern Matron – Physical Health


2017 – Version 10

Striving for perfect care for the people we serve


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NICOTINE MANAGEMENT POLICY Further information about this document:

Document name NICOTINE MANAGEMENT POLICY (Formerly Corporate Smoking Cessation Policy) SA20

Document summary

The policy is concerned with providing a safe, smoke-free environment and health promotion for service users and staff.

The policy supports service users and staff who do not wish to stop smoking in preventing harm to others from second

hand smoke and in managing their nicotine dependency symptoms whilst in trust premises and grounds.

Author(s)

Contact(s) for further information about this document

Joanne Scoltock Modern Matron

Telephone: 0151 471 2396 Email: [email protected]

Published by

Copies of this document are available from the Author(s) and

via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Your Space Extranet: http://nww.portal.merseycare.nhs.uk Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with

SA02: Risk Management Policy & Strategy SA03: Reporting, Management and Review

of Adverse Incidents SA07: Health, Safety and Welfare

SA10: Clinical Risk Assessment Tools (to be applied inconjunction with portfolio of risk assessment tools)

SD29: Physical Health Care of Service Users HR01: Disciplinary Procedures

HR21: Recruitment and Selection SA19: Management Medical Devices Policy

This document can be made available in a range of alternative formats including various languages, large print and braille etc

Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

Version Control:

Version History: Version 1 Smoke Free Policy December 2006 Version 2 Smoke Free Policy June 2008 Version 3 Smoke Free Policy September 2009 Version 4 Smoke Free Policy September 2010 Version 5 Corporate Smoking Cessation Policy April 2013 Version 6 Nicotine Management Policy November 2015 Version 7 Nicotine Management Policy April 2016 Version 8 Nicotine Management Policy February 2017 Version 9 Nicotine Management Policy September 2017

mailto:[email protected]

http://nww.portal.merseycare.nhs.uk/Pages/MCNHSHome.aspx

http://www.merseycare.nhs.uk/


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Version 10 Nicotine Management Policy November 2017


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SUPPORTING STATEMENTS

this document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child/ adult abuse and neglect through their observation of

abuse, or by professional judgement made as a result of information gathered about the child/ adult;

• knowing how to deal with a disclosure or allegation of child/adult abuse; • undertaking training as appropriate for their role and keeping themselves updated; • being aware of and following the local policies and procedures they need to follow if they

have a child/ adult concern; • ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; • participating in multi-agency working to safeguard the child or adult (if appropriate to your

role); • ensuring contemporaneous records are kept at all times and record keeping is in strict

adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session.

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy.


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Contents

1. Purpose and Rationale 5

2. Outcome Focused Aims and Objectives 5

3. Scope 6

4. Duties 6

5. Process/Procedures including E-cigarettes 12

6. Development and Consultation 16

7. Training and Support 17

8. Monitoring 17 9. Supporting Information 18

10. Equality and Human Rights Analysis 19

11. Appendix 1 25 12. Appendix 2 30

13. Appendix 3 34

14. Appendix 4 36

15. Appendix 5 37

Section Page No


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1. PURPOSE AND RATIONALE

1.1 Executive Summary

Nicotine Management forms a central aspect of our intention to improve the health

and wellbeing of Trust Service users and staff. All NHS sites will be smoke free healthcare settings the Trust has agreed a smoke free strategy this policy supports the implementation of the strategy.

1.2 Rationale

1.2.1 The National Institute for Health Care Excellence (NICE - 2013)

recommending smoke free healthcare settings. “Smoking is the largest single cause of premature deaths and preventable

ill-health in England. In England in 2011 among adults aged 35 and over there were around 79,100 deaths (18% of all deaths of adults aged 35 and over) estimated to be caused by smoking and estimated that in 2011, “36% (22,500) of all deaths due to respiratory diseases and 28% (37,400) of all cancer deaths were attributable to smoking” (p.82).

1.2.2 The policy is concerned with providing a safe, smoke free environment

and health promotion for service users and staff. It supports service users and staff who do not wish to stop smoking in preventing harm to others from second-hand smoke and in managing their nicotine dependency symptoms whilst in trust premises and grounds. The policy also supports service users and staff who do wish to stop smoking to access appropriate stop smoking services.

2. OUTCOME FOCUSED AIMS AND OBJECTIVES

2.1 Aims

2.1.1 Ensure that community service users have access to appropriate stop

smoking support and this is addressed fully as part of care planning. 2.1.2 Provide appropriate support to service users and staff to manage the

symptoms of nicotine dependency whilst in trust premises and grounds. 2.1.3 Provide appropriate support for service users and staff to stop smoking. 2.1.4 Protect and improve the health of staff, service users, visitors and

contractors. 2.1.5 Protect both smokers and non-smokers from the danger to their health of

exposure to second-hand smoke. 2.1.6 Set an example to other employers and workforces, particularly in health-

related settings. 2.1.7 Adhere to legislation (The Health Act 2006) to comply with smoke-free

regulations, implemented in mental health services on 1st July 2008.


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2.2 Principles

Smoking is not solely about the exercise of personal choice since its effects clearly impact on the health of others. So, whilst the Trust recognises that some individuals choose to smoke that choice cannot be applied at the expense of another individual’s health. The Trust has to take steps to maintain a healthy environment and comply with statutory provisions. 2.2.1 To ensure that information and support is provided in an appropriate

format taking into account the person’s personal circumstances.

2.2.2 The Trust acknowledges that any searches are done in line with the Human Rights Act 1988, Article 8.

3. SCOPE

3.1 This policy will apply to all staff, service users, visitors, contractors, volunteers and

other persons, who enter Mersey Care NHS Foundation Trust owned or rented buildings (or grounds) including vehicles parked on Trust grounds.

3.2 Its formal adoption of the policy will commence in May 2015. There will be a phased implementation within the divisions.

3.3 All Trust employees, visitors, contractors, volunteers and other persons are not permitted to smoke on Trust premises or grounds during working hours.

3.4 Service users in community settings are asked to provide a smoke free room/environment if they are receiving home visits.

3.5 Staff who do not comply with the policy will be interviewed by their line manager and referred to occupational health for support and advice as appropriate. Should an individual or group of individuals continue to infringe this policy the manager may invoke disciplinary procedures as a means of encouraging adherence to this policy.

3.6 Stop smoking support will be made available to all service users and staff and nicotine replacement therapy (NRT) will be prescribed where appropriate. Staff from all services will be trained in stop smoking support.

3.7 Stop smoking support will be publicised through the Trust website providing guidance, information leaflets and posters.

4. DUTIES

4.1 Board of Directors 4.1.1 Health care providers are under obligation to provide safe care to their service

users and appropriate training to their staff. This duty encompasses ensuring the physical health care of service users whilst under the care of the organisation and the Trust has an obligation to comply with its statutory and regulatory observations.

4.1.2 The Board of Directors has overall responsibility for ensuring that all staff are

appropriately trained and competent to effectively fulfill their role within the organisation and to maintain the safety of services users.


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4.1.3 Ensure that staff, service users, visitors and contractors are made aware of

the policy. 4.1.4 Provide resources to ensure effective implementation. 4.1.5 Ensure that all jobs advertised will state that Mersey Care NHS Foundation

Trust is a smoke free Trust. 4.1.6 Ensure that all Service Level Agreements with other organisations must

contain the following clause ‘Mersey Care NHS Foundation Trust is a smoke free Trust. Smoking is not permitted in all Trust buildings, grounds and all Trust vehicles’.

4.2 Lead Executive Director

The Lead Executive Director for this policy (Executive Director of Nursing) has strategic responsibility for ensuring that appropriate physical health care management is monitored and reported to the board accordingly. The lead is responsible to ensure that all managers are aware of the policy and supported to implement the policy. They will work alongside the Executive Director of Service Development and Delivery and the Director for Service User Safety (who is the Chair of the Health and Safety Committee) who will monitor smoking related incidents.

4.3 Policy Lead The Policy Lead (Modern Matron – Physical Health) will oversee the implementation, promotion and governance of the policy across the Trust. They will be responsible for monitoring and reviewing the policy as necessary.

4.4 Smoke Free Lead The duties of the Smoke Free Lead will be to support all divisions in the implementation of the policy and support both staff and service users by doing smoke free stalls and attending any staff or community meeting when necessary.

4.5 Chief Operating Officer and Associate Medical Director Are accountable for ensuring the standards of this policy are maintained within the service for which they have overall responsibility and ensuring adherence to the policy.

4.6 Employees

All Trust staff have a duty to comply fully with this policy.

4.7 Occupational Health 4.7.1 When joining the Trust, occupational health staff will make new

employees aware of the smoking cessation support services within the Trust.


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4.7.2 Screen all new employees for smoking status.

4.7.3 Support staff to have access to tobacco dependence treatment programs.

4.8 Divisions Service Care Leads, Modern Matrons and Ward Managers are responsible for the following: (a) have a documented action plan in relation to the Trust’s Nicotine

Management Policy; (b) have adequate staff trained to level 2 smoking cessation advisors that will

be easily accessible to service users who require specialist smoking cessation support including nicotine replacement (NRT) and behavioral support;

(c) provide smoking cessation resources such as carbon monoxide monitoring; (d) promote the smoking cessation pathways and choices for service users

and staff; (e) meet the Trust mandated training requirements for staff trained in smoking

cessation; (f) ensure that staff use the electronic service user record to record all

assessments and interventions delivered to support smoking cessation activity, including referral and quit rates.

4.9 Line Managers will ensure:

(a) there is safe and appropriate skill mix within teams to meet the tobacco

dependence needs of service users (either to provide very brief advice or intensive behavioral support);

(b) staff do not facilitate service users to smoke (ie escort a service user off site to

smoke, buy tobacco products, lighters, cigarettes); (c) prior to planned escorted leave, service users will be supported to manage

their nicotine dependence and to remain smoke free whilst outside of Trust premises. Service users will also be informed of the expectation that whilst in the community they will not expose staff members to second-hand smoke;

(d) staff are competent at identifying and recording the smoking status of every

service user in their electronic record; (e) all staff with clinical contact provide very brief advice (VBA – Level 1) to all

smokers (ask, advise, assess, record, act); (f) all smokers are offered support to stop smoking on admission and at regular

intervals throughout their admission and record of intervention is documented;


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(g) all smokers who want to stop smoking are referred to a Level 2 trained Tobacco

Dependence Treatment Advisor;

(h) all smokers who do not wish to permanently stop smoking are offered NRT to manage temporary abstinence from smoking and are referred to a ward Tobacco Dependence Treatment Advisor for consultation. Should this option not be preferred e-cigarettes will then be discussed as an alternative;

(i) every service user that smokes has a personal tobacco dependence treatment

plan; (j) NRT is available in all in-patient areas to manage tobacco withdrawal symptoms

(either for planned abstinence or temporary abstinence); (k) NRT is offered to a smoker within 30 minutes of admission to an in-patient

facility, (please refer to the Trust approved SD12 – MM08 Discretionary Medicines Procedure, which includes NRT products);

(l) ensure staff and service users are aware of the need to adjust medication if

required according to smoking status and this is reflected within individuals care plans;

(m) ward systems are in place so that 1) service users are supplied with an

adequate amount of NRT during periods of leave and on discharge, 2) follow up plans are in place to encourage service users to maintain their abstinence after discharge;

(n) service user information regarding the relationship between smoking and illness

(both physical and mental) are available in service user areas; (o) information on tobacco smoke and medication interactions is available in all

clinical areas; (p) staff appraisals and personal development plans reflect an employee’s training

needs to deliver tobacco dependence treatment; (q) all staff who have clinical contact with service users have completed basic

knowledge training Level 1; (r) there are sufficient staff trained in Tobacco Dependence Treatment Advanced

Skills training (Level 2) to meet the needs of smokers in each clinical area; (s) smoking cessation training is promoted, taken up and translated into practice; (t) staff are fully supported in reminding other people of the Nicotine Management

Policy; (u) comply fully with the policy and provide a suitable role model for staff and

service users; (v) staff do not take smoking breaks during work hours;


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(w) staff who smoke are supported to access smoking cessation sessions via work or at their local tobacco dependence service.

4.10 Clinical Staff working in community settings will:

(a) ask and record each service users smoking status at the first contact and

provide very brief advice to all smokers or as soon as possible if the service user is unwell;

(b) review each service user’s smoking status regularly and at each CPA meeting; (c) refer all service users who wish to stop smoking to a smoking cessation

specialist; (d) ensure that blood plasma levels are monitored for those who are embarking on

a stop attempt; (e) actively engage service users, their family and carers about the benefits of

stopping smoking; (f) ask all service users to refrain from smoking for at least 30 minutes prior to their

contact; (g) ensure that service users are aware of the trusts smoke free status; (h) ensure that all welcome packs and promotional materials provided about the

service describe the smoke free status.

4.11 Level 2 Tobacco Dependence Treatment Advisors will: (a) support smokers who wish to make a planned stop attempt; (b) support smokers who do not wish to stop smoking during an in-patient stay, to

manage temporary abstinence from tobacco; (c) deliver one to one, drop in and group based treatment to service users and staff

who smoke; (d) following a referral from ward/community staff, carry out a comprehensive

assessment of a smoker’s needs, including the severity of tobacco dependency, service user preference for treatment, assessment and recommendation for the use of stop smoking pharmacotherapies;

(e) if authorised to administer NRT under the Trust’s discretionary medicines policy

for NRT or following consultation with a prescriber, facilitate access to pharmacotherapy in line with Trust protocols;

(f) liaise with prescriber (ward, community, primary care) re potential interactions of

stopping (and restarting smoking, ie irregular patterns of smoking) and psychotropic medication;


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(g) minimise withdrawal symptoms through optimising adherence to pharmacotherapy (eg correct technique, sufficient dose and length of treatment);

(h) provide intensive psychological, behavioral and social support to assist the smoker:

(i) understand the personal relevance of smoking, (ii) cope with cravings, (iii) maximise motivation and commitment, (iv) maintain abstinence; (v) maximise mental health, (vi) maximise physical health.

4.11.1 In collaboration with the smoker and their community team, formulate,

document and evaluate personal stop smoking plans. 4.11.2 For service users who have made a quit attempt whilst in hospital and

who wish to maintain their abstinence, ensure a seamless handover to the local community NHS Stop Smoking Service (or Level 2 trained advisor in the CMHT) so that service users can receive follow up care for up to 4 weeks.

4.11.3 Attend refresher training as required.

4.12 Clinical Staff Working in Service User settings will:

(a) ask and record a service user’s smoking status on admission and provide very brief advice to all smokers. They will inform the service user of the Trust’s Nicotine Management Policy and smoke free status; On admission any smoking paraphernalia/cigarettes will be removed and given back when the service user next leaves the hospital or handed over to carers to take home. Refer all smokers who want to stop smoking to the ward or on-site in-patient Tobacco Dependence Treatment Advisor; “Services are likely to require patients to hand over any smoking materials. Some services return these on the next occasion the person next leaves the hospital site. Others only return confiscated smoking materials upon eventual discharge, which could be challenged under the MHA Code of Practice principle of least restriction” Care Quality Commission: Smoke free policies in mental health services 2017. When services users have unsupervised leave they may request smoking property to be returned. They must be encouraged to leave the items at home, or dispose of them before returning to the ward. If they do return with the items will need to be given back to the staff.

(b) work closely with advisors to support the service user to maintain abstinence;


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(c) liaise with the ward/in-patient Tobacco Dependence Treatment Advisor to ensure smokers who do not want to quit, are supported in managing temporary abstinence from tobacco during an in-patient admission;

(d) actively engage smokers in conversations about the benefits of quitting;

(e) educate about and recommend the use of NRT to all smokers;

(f) review care plan at each ward round, CPA or clinical review meeting;

(g) monitor adherence with NRT daily;

(h) ensure service users are supplied with an adequate amount of NRT during

periods of leave and on discharge;

(i) ensure follow up plans are in place to encourage the service user to maintain their abstinence after discharge. Refer to the local community NHS Stop Smoking Service on discharge;

(j) ensure that service users have access to a variety of activities and fresh air

during their admission to support their smoke free compliance; (k) ensure that service users are provided with advice and support to actively

manage stress and nicotine withdrawal.

5. PROCESS/PROCEDURES

5.1 Key Points The Trust promotes nicotine management on Trust premises.

No smoking by Service Users and Visitors is permitted anywhere on Trust premises. Staff and contractors are not permitted to smoke anywhere on Trust premises. 5.2 General Issues with Smoking and Psychiatric Treatment

5.2.1 Tobacco use may lower blood levels of certain medications used in psychiatry.

Smoking cessation may therefore result in increased drug levels in the blood with a concordant reduction in amount required. A Trust pharmacist should be contacted for specific advice on interactions between tobacco and psychiatric medication and assist service users understanding of how this happens and the benefits to be gained from stopping smoking in respect of a potential reduction in the amount of prescribed medication required.

5.2.2 Cigarettes or tobacco related products must not be used as a reward for good

behavior or as an incentive to diffuse an aggressive situation. Staff who are supporting people who may become challenging in relation to these issues are supported through HR09.

5.2.3 To ensure that information and support is provided in appropriate format

taking into account the person’s personal circumstances.

5.3 Application to Service Users


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5.3.1 The Trust will promote nicotine management by ensuring that all service users who smoke are advised of the health risks and are given the opportunity and support to stop smoking. Where service users decline this opportunity and choose to smoke they must be advised of the Trust smoke free environment. Such discussions must be formally recorded in the service users’ clinical notes.

5.3.2 Staff will need to be sensitive when approaching the topic of smoking

cessation, especially when a service user has just been admitted. However, all service users who smoke should be offered advice and support to stop smoking and informed of the benefits to be achieved as consequence by staff trained in smoking cessation interventions.

5.3.3 Individual care plans and health promotion packages must ensure that the

potential impact of smoking cessation on concurrent drug therapy is assessed, appropriately planned for and discussed with the medical team. Close monitoring for side effects and signs of toxicity of prescribed medication should be provided as part of the care plan, where potential impact has been identified. Individual care plans should also identify action to be taken if a service user continues to smoke whilst using nicotine replacement therapy (NRT) or e-cigarettes.

5.3.4 When a service user is discharged the care plan will be clearly communicated

to the new service and the service user’s GP to ensure continuity of care. 5.3.5 Supported living schemes and community residential settings cannot be

regarded in the same way as in-patient services. Such settings should be regarded as if they were a service user’s home, except where the care package is provided by the trust and that this further involves communal and shared living space. In such circumstances the policy should be adopted.

5.3.6 Service users visited in their own home cannot be required not to smoke but

will be asked to cease smoking for the duration of any visit. In some cases it may be necessary to arrange for visits to take place in some other location than the service user’s home. Leaflets explaining the Trust’s smoke free position will be made available to service users.

5.4 Community Service Users

5.4.1 All service users new to the Trust services where appropriate will be

informed of the Nicotine Management policy at the earliest opportunity. They will be assessed for stop smoking support and a smoking intervention plan will be implemented. Service users who do not wish to stop smoking will be encouraged to use NRT, or e-cigarettes if preferred to assist with nicotine withdrawal symptoms and facilitate smoking abstinence during an in-patient stay. Each offer of stop smoking support and NRT will be clearly documented in the intervention plan and recorded in the clinical record. The next review date will also be recorded. In order to protect staff from second hand smoke, service users will be asked to provide a smoke free room (a room not smoked in for at least 30 minutes prior to a visit) for home visits and be asked to refrain from smoking throughout the visit (please note this does not apply to e-cigarettes). Failure to comply with this will mean that an alternative venue is arranged for visits, if appropriate. All community appointment letters will inform


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service users of the Nicotine Management Policy, using the following wording:

Mersey Care NHS Foundation Trust is a Smoke Free Organisation

“We have a duty to protect staff from second hand smoke. If you are receiving a visit from a member of our staff then we request that you make a room available that is smoke free (not smoked in for a period of 30 minutes) Both yourself and your family/others present are requested not to smoke during our visit. If you are unable to provide such a room then please discuss with your care co-coordinator so that alternative arrangements can be made.”

5.4.2 Support and information will be offered to all service users. Those service

users who reside in supported living schemes or community residential settings and have private tenancy agreements cannot be regarded in the same way as those in in-patient services. Such settings are deemed as if they were a service user’s home. Therefore the application of the policy concerning exposure to second hand smoke will need to be negotiated with the service user and housing provider (if appropriate) in order that maximum protection is afforded to staff and other service users, ie use of an identified smoking area.

5.5 Staff

5.5.1 The Trust recognises that smoking is addictive and adherence to this

Nicotine Management Policy will be a challenge for some members of staff. Staff will be able to access stop smoking support and advice from appropriately trained workplace colleagues, the occupational health service and local NHS stop smoking services. The Trust will support staff in accessing these services, time utilized attending smoke free services will be reimbursed in agreement with their line manager up to seven and a half hours. Stop smoking services can offer help, advice, and access to smoking cessation treatment, pharmacotherapy, and problem solving to staff who wish to stop smoking. Staff who do not want to stop smoking will be encouraged to use NRT to manage the symptoms of nicotine dependency whilst on duty. Job advertisements will include reference to the Nicotine Management Policy and indicate that the adherence will be contractual. Tenders and contractors with the Trust will stipulate adherence to this policy as a contractual condition. Contracts will be modified to reflect this.

5.5.2 To ensure that everybody entering Trust sites understands that smoking is

not allowed in the buildings and grounds, clear signs will be displayed. The Trust will not support extra time for smoking in addition to standard breaks. All employees are responsible for ensuring that the Trust’s policy for a smoke free site is reinforced within the buildings and grounds. Staff must not smoke with service users or carers under any circumstances. The Trust prohibits the selling and purchasing of tobacco products and associated paraphernalia on site or during working hours.

5.6 Staff Including Locums, Bank, Agency and Volunteers are Not Permitted to

Smoke:


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(a) in cars parked on Trust premises;

(b) outside entrances to Trust premises;

(c) when travelling on Trust business.

5.6.1 Staff are not permitted to smoke or vape during their hours of duty. They

can however smoke away from the building and grounds in their 30 minute unpaid break.

5.6.2 When attending meetings or other events at venues where smoking is

permitted, staff members are expected not to smoke. It is also expected that staff should not be seen to be smoking in public whilst wearing a uniform or Trust badge.

5.6.3 Whilst every effort will be made to protect staff from second hand smoke,

the Trust recognises that there will be occasions when staff visit service users in their own homes and which may expose staff to smoke. Service users can legitimately be asked to cease smoking for the duration of the visit, but clearly this cannot be enforced. Leaflets have been made available to service users explaining the Trust’s position regarding smoke free and why, when they are visited by a member of staff employed by the trust in their own homes as part of treatment, they may be asked to refrain from smoking.

5.6.4 To provide staff with the knowledge and skills to support service users

who wish to stop smoking, appropriate training can be accessed via the NHS Stop Smoking Services as well as other avenues. Training places will be advertised as part of the Trust’s training prospectus.

5.7 Visitors and Contractors

5.7.1 Visitors to the Trust will not be allowed to smoke anywhere on Trust

premises, or outside entrances to its premises, at any time. All contracts placed to tender must include a requirement that this policy is complied with.

5.7.2 Staff safety must always be paramount. Under no circumstances should any member of staff be encouraged to enforce an element of the policy if they believe they would be placed at risk in doing so. They should raise immediately with line manager and complete an incident form.

5.8 In-patient Areas

5.8.1 Service users admitted to an in-patient ward will have their smoking status

recorded and a nicotine management intervention plan implemented. Service users will not be permitted to smoke on Trust premises. Where a service user does not wish to stop smoking then the nicotine intervention plan should focus on providing NRT and psychological support to enable the service user to deal with the symptoms of nicotine dependency whilst an in-patient. Service users who are already receiving smoking cessation pharmacotherapy prior to their admission will continue to receive support and remain in possession of their own supply of pharmacotherapy, if this is assessed to be safe/appropriate.


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5.8.2 Each offer of stop smoking support and smoking cessation pharmacotherapy

will be clearly documented in the intervention plan. The next review date will also be recorded.

5.9 E-cigarettes

After careful consideration and consultation it has been concluded that e-cigarettes may support compliance with this policy and help some smokers manage their nicotine dependence. The Trust-wide Nicotine Management Group has indicated that there is a desire among some patients and staff to use e-cigarettes to support cutting down or quitting tobacco. However, it is critically important that e-cigarettes do not simply replace cigarettes and a culture of facilitating e-cigarette breaks for groups is avoided.

The Trust believes that e-cigarettes may help some smokers move away from using harmful burnt tobacco towards a cleaner form of nicotine delivery. E-cigarettes are not recommended as a first line treatment option, and cannot be used by patients who are under 18 years. They should be considered after smokers have declined all other options set out in the Tobacco Dependence Treatment Pathway (Appendix 1), this also applies to pregnant women (Smoking in pregnancy challenge group (2017). All e-cigarette users must have in place a risk assessment and care plan that details how the smoker will be supported to use his/her device. As new evidence emerges about e-cigarettes the Trust will review this position. Appendix 2 provides some background information and Appendix 3 provides guidance for staff to help facilitate e-cigarette use safely. Following consideration and risk assessment High Secure Services have prohibited the use of e-cigarettes due to the significant security and safety risk that they pose for this service.

5.10 Managing Non Adherence to the Policy

5.10.1 It is recognised that some individuals may be unable to adhere to this policy.

It is necessary for the individual clinical team responsible for the person’s care to visit this in the context of the individual‘s needs from a mental health perspective, as well as responsibility in relation to other service users and staff that may be directly affected by this non adherence or resistance to the necessary support being offered by the care team. This includes those within the addiction service who are withdrawing from other substances.

5.10.2 Where service users may be unable to adhere to the policy their plan of

care will be reviewed accordingly to maintain the safety of themselves and others. This may lead to environmental restrictions and increased searches.

5.10.3 Some service users will lack the mental capacity to either understand why

or repeatedly forget that they cannot smoke. It is important to recognise that this group will need to be sensitively supported when assisted to stop smoking.

5.10.4 All Trust staff are expected to promote a smoke-free environment and

healthy living. Staff should avoid condoning smoking. All Trust staff are


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discouraged from purchasing or providing tobacco products. If any staff member breaches the policy then in the first instance line managers should discuss the issues with them to ensure they fully understand the smoke-free policy. If staff continue to breech the policy then actions through the disciplinary process may be appropriate.

5.10.5 All instances of breaches of this policy and fire regulation are to be

recorded and reported as per adverse incident policy and must be reviewed by the multi-disciplinary team.

6 DEVELOPMENT AND CONSULTATION

6.1 This policy has been developed by the Trust-wide Nicotine Management Group

with Service User Representation, Clinical Managers, Modern Matrons, Lead Nurses and Risk Managers in consultation with the Trust Legal Advisors and Local Authority Smoke Free Enforcement Officers as well as service user forums and governance groups. It will be reviewed on a yearly basis or if there are any changes in legislation.

6.2 Managers of smoke-free premises and vehicles have a duty to prevent smoking

within workplaces and vehicles. Managers also have a duty to monitor the smoke-free arrangements within those premises and vehicles.

6.3 Breaches will be dealt with in accordance with appropriate Trust policy and

reported into the Trust Health and Safety Committee. Divisions will monitor the number of incidents within their area and review risk assessments, actions taken, interventions and care plans as appropriate. Environmental audits should include observation of adherence to this policy.

7 TRAINING AND SUPPORT

All our staff will be Level 1 trained. They will be able to offer advice and support, and signpost service users and work-place colleagues to Stop Smoking Services. Staff trained to Level 1 can actively support interventions planned by staff trained to Level 2. Divisional Lead will identify clinical/nursing staff that will be trained as Stop Smoking Advisor (Level 2) enabling them to deliver stop smoking intervention and advise medical staff on the most suitable prescription of NRT for the individual. Identified staff will be trained to deliver Levels 1 and 2 Stop Smoking Intervention Training to other Trust staff. Where feasible and where there is sufficient demand, stop smoking clinics will be available on site to provide the appropriate support to both staff and service users to help them stop smoking.

8 MONITORING

8.1 Day-to-day responsibility for ensuring compliance of this policy lies with Departmental

Managers and their nominated deputies. Staff who do not comply with this policy will be interviewed by their line manager and signposted for smoking cessation support as appropriate.

8.2 All contractors, visitors, volunteers and service users to be made aware of the policy and asked to comply. It will be the responsibility of managers in the local areas to ensure awareness of the policy.

8.3 Managers have a duty to prevent smoking within all Trust premises, vehicles and grounds.


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8.4 Each division will monitor the number of Datix/Ulysees incidents, and complaints

within their area and review risk assessments, actions taken, interventions and care plans as appropriate. Responsibility lies with Clinical Service Managers.

8.5 The Trust will monitor the number of staff that undertakes Level 1 care skills and

Level 2 advanced training. 8.6 Reporting of Smoking Related Incidents

8.6.1 All members of staff should use the Datix system to promptly share information about any difficulties with the implementation of the Nicotine Management Policy.

8.6.2 Analysis of all recorded incidents will enable the Trust to be proactive and re-

active to reduce the impact and likelihood of future recurrence.

8.6.3 Staff should also use Datix to record incidents when services users refuse

admission or self-discharge against medics’ advice because of the Nicotine Management Policy.

8.6.4 The Trust will monitor the number of complaints received related to the

implications of the Nicotine Replacement Policy.

9 SUPPORTING INFORMATION Brown S, Kim M, Mitchell C et al (2010), Twenty-five year mortality of a community cohort with schizophrenia. British Journal of Psychiatry 196: 116-21 Cancer Research UK, Smoking and cancer: What’s in a cigarette? (www.cancerresearchuk.org) Chang C-k, Hayes RD, Perera G, Broadbent MTM, Fernandes AC, et al. (2011) Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London. PLoS ONE 6(5):19590. doi:10.1371/journal.pone.0019590 Care Quality Commission (2017): Smoke free policies in mental health services. Department of Health (2004) Scientific Committee on Tobacco and Health (SCOTH), Secondhand Smoke: Review of evidence since 1998. DOH, London Department of Health (2011a) No Health without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages. DOH, London Department of Health (2011b) The NHS Outcomes Framework 2012/13. DOH , London Doll, R. Petro, R.Boreham, J. Sutherland, I. (2004) Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ, doi: 10.1136/BMJ.38142.554479.AE Health Act (2006), HMSO, UK Health and Safety at Work Act (2004), HMSO, UK

http://www.cancerresearchuk.org/


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Health Equalities Group (2014) Breathing Space, Your Home - Our Workplace – Protecting Community Staff from Exposure to Secondhand Smoke Mersey Care NHS Trust (2015) SD12, Handling of Medicines. MM08 Discretionary Medicines Procedure Mersey Care NHS Trust (2015) SD 29, Physical Health Care – Local Division NICE (2013) Smoking cessation in secondary care: acute, maternity and mental health services. PH 48 Royal College of Nursing (2006) Protecting Community staff from exposure to second-hand smoke RCN best practice guide for staff and managers. RCN, London The Health and Social Care Information Centre (2012) Statistics on Smoking: England. HSCIS World Health Organisation (2013) Questions and Answers on electronic cigarettes or electronic nicotine delivery systems. WHO


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10 Equality and Human Rights Analysis

Title: Nicotine Management Policy

Area covered: Trust-wide

What are the intended outcomes of this work? The policy provides guidance for staff and service users around smoking cessation. Review of the assessment and the policy– reviewed by George Sullivan and Cathie Thomas on12th April 2016. No changes found. Reviewed 15th Nov 2017 –No change Who will be affected? Service users and carers and all staff, all visitors including health professionals and contractors. Reviewed 15th Nov 2017 –No change Evidence

What evidence have you considered? View obtained from Jim Wiseman (Mental Health /Law) Team In-service user admission under the Mental Capacity Act 2005 If P lacks capacity to make an informed decision about hospital in-service user admission BUT does NEITHER try to leave NOR object to treatment then s/he must be managed under the MCA (a further assessment for admission under the Deprivation of Liberty Safeguards – DoLS – is required at this point). If P objects to being prevented from smoking then P is objecting to part of the treatment package, and hence, hospital admission. At this point P must be assessed for detention either under the MHA 1983 or DoLS (dependent upon all the circumstances in each case – as a guide if P is only objecting to being prevented from smoking then DoLS is more likely to be applicable. If P is objecting to additional aspects of her/his care/treatment/admission then application for detention under the MHA should made). • Informal Admission (s.131 MHA) If P has capacity to consent to informal admission (and does so consent) s/he is consenting to the admission itself AND the package of care that goes with it (including not being allowed to smoke). In order to consent (or not) P must therefore be informed of the rules relating to smoking. If P has capacity and refuses to comply with the no smoking rule, then P is refusing part of the treatment package, and hence refusing informal admission. At this point P must be assessed for detention under the MHA 1983. • Where P is formally detained under the MHA or DoLS If P is detained under either the MHA or DoLS, s/he may be prevented from smoking. The key Principles of both the MCA and the MHA must still be applies in all cases. Consequently, If P continues to try to smoke then efforts to stop her/him must be the least restrictive intervention, necessary,


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appropriate, safe, in P’s best interests, and proportionate to outcomes. The equality and human rights analysis 2013 Human Rights judicial review and appeal. Reference: Queen’s Court Bench Division Cite No (2008 EWHC 1096, Lord Justice Pill and Mr Justice Silber). Reviewed 15th Nov 2017 For this review the policy has detailed research and information which has led to the inclusion of the use of E-cigarettes to support the smoke free environments within the Trust. Disability (including learning disability) This document does not address the issue of capacity. In particular in relation to learning disabilities when a service user is ill due to their mental health and people with Dementia. Reviewed 15th Nov 2017 – see cross cutting Sex No evidence No change following review. 12/4/16 Reviewed 15th Nov 2017 see cross cutting Race No evidence No change following review Reviewed 15th Nov 2017 See cross cutting

Age This document does not address the issue of capacity of older people and those with dementia who lack capacity and refuse to stop smoking. No change following review. 12/4/16 Reviewed 15th Nov 2017 see cross cutting Gender reassignment (including transgender). No evidence No change following review. 12/4/16 Reviewed 15th Nov 2017 see cross cutting Sexual orientation No change following review. 12/4/16 No change following review. Reviewed 15th Nov 2017 see cross cutting Religion or belief No evidence No change following review. 12/4/16 Reviewed 15th Nov 2017 see cross cutting


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Pregnancy and maternity No evidence No change following review. 12/4/16 Reviewed 15th Nov 2017 see cross cutting Carers No evidence No change following review. 12/4/16 Reviewed 15th Nov 2017 see cross cutting Other identified groups No evidence. No change following review. 12/4/16 Reviewed 15th Nov 2017 see cross cutting Page 16-5.10 Note the need to include the specific issues related to people who are accessing our addictions services who may find the requirement not to smoke an additional pressure whilst withdrawing from other substances. Cross Cutting No evidence No change following review. 12/4/16 Page 7 -4.1.7 To include the requirement for the smoke free lead to make available information in a variety of formats or support the provision of information in appropriate formats to the person that this is provided to. This may also include support where someone lacks capacity. Noted the need to ensure that people have information provide in an appropriate format across the policy: Within the Principles 2.2 page 6 – add a statement detailing the need to address capacity and to have information provided in a manner that is appropriate to the person it is being presented to. This includes Page 8-4.8, 4.9 (h), 4.10 (h) To ensure that the Level 2 training specifically includes guidance for the advisors on the provision of information to people who have communication issues or lack capacity either short or long term. To enable information and support to be available in an appropriate format for the individual who requires it. Page 12 -13 5.3, 5.3.6, 5.4.1, 5.4.2, 5.6.3 5.9 all areas relate to the provision of information to be provided in an appropriate format. Recommend to include an overall statement within 5.2 –General issues – to include a statement requiring the need to provide information to be in an appropriate format to cover this whole section. Page 16 5.10.3 Noted the inclusion to address issues when a person lacks capacity – support for this has been added as a part of Level 2 Training and the role of the Smoking Advisors. Appendix 1 - 1st paragraph – recommend the inclusion of ‘culture’ within the list of significant factors.

Human Rights Is there an impact?


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How this right could be protected? Right to life (Article 2) Not engaged this policy and procedure is aimed at

improving wellbeing.

No change following review.

Reviewed 15th Nov 2017 – no change

Right of freedom from inhuman and degrading treatment (Article 3)

Not engaged.


Reviewed 15th Nov 2017 - no change

Right to liberty (Article 5) Not engaged.



Right to a fair trial (Article 6) Not engaged.



Right to private and family life (Article 8)

Article 8 considered within Judicial review/appeal. Smoking not deemed a human right. Hospital accommodation not considered to be a ‘home ‘for service users within High secure services.

In terms of autonomy judgement states that service users within mental health services could expect autonomy to be restricted in relation to health issues.

No change following review. April 2016

Review 15th Nov 2017

Page 11 4.11(a) and Page 16. 10.2 This addresses the request to remove items related to smoking and the possible need to address non adherence to the policy resulting in an increase in searches. – Recommend the inclusion of a statement to detail the Trusts understanding the implications of the Human Rights Act 1998 within this policy and the importance of understanding the need to have consistent and effective recording of decisions made re searching and removal of personal belongings and the need for proportionality within the decision making process. In line with the Trust search policy.

Right of freedom of religion or belief No Issues identified.


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(Article 9) No change following review.


Right to freedom of expression Note: this does not include insulting language such as racism (Article 10)

No Issues identified within discussions.



Right freedom from discrimination (Article 14)

No evidence.



Engagement and Involvement

Staff side organisations were consulted in relation to this policy. Reviewed 15th Nov 2017 - no change Summary of Analysis Eliminate discrimination, harassment and victimisation This policy seeks to address the positive aspect of smoking cessation but also acknowledges that individuals may still make the choice of smoking in areas other than high secure services. To comply with legislation smoking cannot be allowed within buildings; however there is room in this policy to allow services to designate external smoke areas for in service user service users. This will allow those who choose to continue to smoke and who are too ill to be able to access the community to no longer feel discriminated against in some areas. It also seeks to address the issue of covert smoking in in-patient areas which constitute a serious fire hazard. No change following review. Reviewed 15th Nov 2017 This policy has now introduced the use of E-cigarettes as a supportive measure to enable people to stop/reduce the intake nicotine and the impact of this upon others. Advance equality of opportunity Not applicable No change following review Reviewed 15th Nov 2017 This policy will ensure it directly supports people where communication or capacity has an impact on the provision of support and information.

Promote good relations between groups Not applicable No change following review


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Reviewed 15th Nov 2017 - no change What is the overall impact? The impact of this policy is intended to be positive. No change following review Reviewed 15th Nov 2017 - no change Addressing the impact on equalities There needs to be greater consideration re health inequalities and the impact of each individual development /change in relation to the protected characteristics and vulnerable groups Not applicable. No change following review. Reviewed 15th Nov 2017 - no change Action planning for improvement

Detail in the action plan below the challenges and opportunities you have identified. Include here Not applicable No change following review Reviewed 15th Nov 2017 – Action plan to be put in place – see below. For the record Name of persons who carried out this assessment: The Policy was subject a equality and Human Rights Analysis in April 2013 Meryl Cuzak Equality and Human Rights Lead George Sullivan Equality and Human Rights Advisor Review 12th April 2016 George Sullivan Cathie Thomas Smoking Cessation Officer Reviewed 15th Nov 2017 Meryl Cuzak Equality and Human Rights Lead Peter Terry Smoking Cessation Officer Date assessment completed: Review 12th April 2016 Review 15th Nov 2017 Name of responsible Director: Executive Director of Nursing – Ray Walker Date assessment was signed:


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12th April 2016 Executive meeting Nov 2017


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Action plan template This part of the template is to help you develop your action plan. You might want to change the categories in the first column to reflect the actions needed for your policy. Category Actions Target

date Person responsible and their area of responsibility

Human Rights

Page 11 4.11(a) and Page 16. 10.2 Add in a statement within Principles- Page 6 detail the Trusts understanding the implications of the Human Rights Act 1998 within this policy and the importance of understanding the need to have consistent and effective recording of decisions made re searching and removal of personal belongings and the need for proportionality within the decision making process. In line with the Trust search policy.

Other identified groups. Monitoring

Page 16-5.10 Include a statement that details the specific issues related to people who are accessing our addictions services who may find the requirement not to smoke an additional pressure whilst withdrawing from other substances. To complete a monitoring process for people within addiction services who leave treatment due to the no smoking policy .

Increasing accessibility

Page 7 -4.1.7 To include the requirement for the smoke free lead to make available information in a variety of formats or support the provision of information in appropriate formats to the person that this is provided to. This may also include support where someone lacks capacity.


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Page 6 -2.2 Within the Principles– add a statement detailing the need to address capacity and to have information provided in a manner that is appropriate to the person it is being presented to. Page 12 -13 5.3, 5.3.6, 5.4.1, 5.4.2, 5.6.3 5.9 all areas Include an overall statement within 5.2 –General issues – to include a statement requiring the need to provide information to be in an appropriate format to cover this whole section. Page 16 5.10.3 Level 2 Training and the role of the Smoking Advisors to include how to address issues when a person lacks capacity Page 8-4.8, 4.9 (h), 4.10 (h) To ensure that the Level 2 training specifically includes guidance for the advisors on the provision of information to people who have communication issues or lack capacity either short or long term. Enable information and support to be available in an appropriate format for the individual who requires it. Appendix 1 - 1st paragraph –include ‘culture’ within the list of significant factors.


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Appendix 1 –Trust Tobacco Dependence Treatment Pathway Introduction Tobacco dependence is a treatable, chronic and relapsing condition. The treatment needs of a smoker will differ slightly according to their smoking history and behaviour, age, gender, socioeconomic status, mental health needs, use of other substances and culture, if they are an inpatient or outpatient and their personal choice about receiving support. However there are essential steps within the tobacco dependence treatment pathway that apply to all smokers. The aim of the tobacco dependence treatment pathway is to: 1. ensure we identify the smoking status of every current patient in receipt of inpatient and community care.

2. ensure early diagnosis of severity of tobacco dependence.

3. offer every smoker Nicotine Replacement Therapy (NRT) within 30 minutes of arrival to an inpatient service.

4. offer evidence-based pharmacological, psychological and psycho-education treatment to all smokers in receipt of inpatient and community care.

5. ensure smokers receive continuous, efficient care and treatment at transition points across the pathway.

6. ensure the Trust meet the recommendations of the NICE guidelines for Smoking: acute, maternity and mental health services1 and Smoking: harm reduction2

The first part of these guidelines describes support during an inpatient stay and then goes on to describe support for people using community services. As the pathway develops in response to evaluation and feedback from clinicians, patients and carers, we will update it at regular intervals. In Patient Pathway STEP 1: Identification of smokers The first step in treating tobacco dependence is to identify current tobacco users. Ask every patient if they currently smoke tobacco. Record smoking status in the designated section of the electronic patient record. The identification and recording of patient’s smoking status needs to be completed regularly, i.e. on admission and discharge from hospital and as part of Care Programme Approach (CPA) reviews. STEP 2: Advise and offer support To comply with the Trust’s Nicotine Management Policy and the NICE guidelines, smokers will need to abstain from smoking during an inpatient admission, whilst in Trust buildings and grounds. Making an attempt to permanently stop smoking is an opportunity not an obligation. During an inpatient admission a smoker has three options: OPTION 1: to temporarily abstain from smoking whilst in buildings and in the grounds, with pharmacological and/or psychological support OPTION 2: to temporarily abstain from smoking whilst in buildings and in the grounds, without pharmacological and/or psychological support OPTION 3: to use the opportunity to make a sustained quit attempt, with pharmacological and/or psychological support


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Regardless of which option the patient chooses, every smoker should be offered NRT to manage their tobacco dependence within 30 minutes of arrival to an inpatient unit. This should be followed up by the offer of tobacco dependence treatment support from a smoking cessation advisor.

Offering support to quit or manage tobacco withdrawal symptoms during a period of temporary abstinence, rather than asking a smoker how interested are they in stopping or telling a person they should stop, leads to more people making a quit attempt. The most effective method of managing tobacco withdrawal symptoms during a period of temporary abstinence is with combination NRT (i.e. a patch and oral product) and intensive behavioural support. Advising smokers that stopping smoking is one of the best things they can do for their health and wellbeing is recommended by the Department of Health. The most effective method of quitting is with either combination NRT (i.e. a patch and oral product) or intensive behavioural support. Should all the above options of pharmacological and psychological support be declined e-cigarettes should then be discussed as an alternative.

1 NICE (2013) Smoking: acute, maternity, mental health services. PH48 2 NICE (2013) Smoking: harm reduction. PH45


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Appendix 2 – Background Information re - Electronic cigarettes What are electronic cigarettes (e-cigarettes)? E-cigarettes are battery powered devices that deliver nicotine via inhaled vapour. Devices come in many shapes or forms, sometimes resembling cigarettes, but others resemble pens or gadgets. They commonly comprise a battery-powered heating element, a cartridge containing a solution principally of nicotine in propylene glycol or glycerine, water (frequently with flavouring), and an atomizer that when heated vaporises the solution in the cartridge enabling the nicotine to be inhaled (it should be noted however that some e-cigarettes do not contain nicotine). E-cigarettes can be disposable, rechargeable or refillable. E-liquids come in various different volumes, concentrations and flavourings. An estimated 2.8 million people in the general population in Great Britain currently use e-cigarettes, the vast majority of whom are smokers or recent ex-smokers (ASH 2016). Recent reports from Public Health England (PHE) and the Royal College of Psychiatrists (RCP) have summarised the evidence on the impact of e-cigarettes on smoking in England (McNeill et al 2015, Royal College of Physicians 2016). These reports concluded that e-cigarettes appeared to be effective when used by smokers as an aid to quitting smoking. E-cigarettes offer a much less harmful alternative to tobacco for dependent smokers. Are electronic cigarettes safer than ordinary cigarettes? As e-cigarettes do not contain tobacco and are not burnt, they do not result in the inhalation of cigarette smoke which contains about 4000 constituents, around 70 of which are known to cause cancer. E-cigarette vapour contains far fewer chemicals and those that are found have much lower levels than in cigarette smoke. E-cigarettes are therefore regarded by most experts as much safer delivery devices for nicotine (Public Health England 2016). This does not mean that they are completely safe, but they are envisaged to be much less harmful than cigarettes. The RCP recently indicated that the hazard to health arising from e-cigarettes was unlikely to exceed 5% of the harm from smoking tobacco. Do e-cigarettes help smokers to stop? There is evidence from a Cochrane review (Hartmann et al 2016) which assessed two randomised controlled trials that e-cigarettes may help some smokers to stop, corroborated by surveys and case reports. A large cross-sectional analysis of a representative sample of the English population found that those who used e-cigarettes in their quit attempts were more likely to report that they had stopped, than those who used a licensed nicotine replacement product over-the-counter or no cessation aid (Brown et al 2014). More recent data from the same survey indicated that changes in prevalence of e-cigarette use in England have been positively associated with the success rates of quit attempts, and estimated that e-cigarettes may have contributed about 18,000 additional long-term ex-smokers in 2015(Beard et al 2013). There is some evidence that the newer generation e-cigarette devices are more helpful for smoking cessation compared with some of the older disposable models (Hitchman et al 2015). This is likely to be due to improved efficiency of delivering nicotine in the newer devices. Two small pilots of e-cigarettes (first generation devices) with people with serious mental illness were positive regarding reduction/cessation of cigarette smoking (Caponetto et al 2013,Hickling et al 2016) and without an exacerbation in psychopathology. What concerns have been raised by e-cigarettes? E-cigarettes were first introduced onto the market in the UK in 2004 so there have been no long-term health studies. However a recent study examined levels of known toxins in urine of e-cigarette users who had used them exclusively for around 17 months and found much lower levels of these substances compared to cigarette smokers, and e-cigarette users had similar levels to a group of long term users of nicotine replacement therapy. There have been other concerns that: 1. e-cigarettes resemble ordinary cigarettes and therefore re-normalise smoking. The PHE and RCP reports found that there is currently no evidence to support this as smoking prevalence continues to decrease, both among adults and youth, in the UK and other countries such as US where e-cigarettes are prevalent;


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2. Simply replacing some cigarettes with e-cigarettes may confer little benefit. Some dual use is inevitable, but the toxins study reported above, did indicate that e-cigarette users who also smoke did not have significantly lower levels of toxins, so an important message is that e-cigarette users need to give up smoking completely as soon as possible; 3. some e-cigarettes are produced by the tobacco industry – this is indeed true. Whilst e-cigarettes were developed originally by a smoker wishing to stop smoking, and independent companies, the tobacco industry is increasingly involved in this area; 4. and they are not tightly regulated in terms of their content and delivery. From May 2017, all e-cigarettes on the UK market need to comply with an EU regulation on electronic cigarettes (see below). 5. There is a potential fire risk that these devices may present, for example if an incorrect charger is used or if the device is left charging for longer than recommended. It is important however to recognise that the fire risk from tobacco cigarettes is much higher and the fire risk caused by other commonly used devices such as mobile phones and MP3 players is similar. 6. E-cigarettes must not be used near naked flames or oxygen. How are e-cigarettes regulated? Since 20 May 2017 all e-cigarettes in England on the consumer market need to be compliant with new regulations introduced through the European Union tobacco products directive. These regulations include controls on content and packaging, such as child resistant/tamper proof packaging, must be protected against breakage and leakage and capable of being refilled without leakage, must deliver a consistent dose of nicotine under normal conditions, must contain a health warning, and tanks and cartridge sizes must be no more than 2ml in volume and nicotine strengths of liquids must be no more than 20mg/ml. Manufacturers can apply for a Medicines & Healthcare products Regulatory Agency (MHRA) licence for e-cigarettes which will allow them to be used for smoking cessation, and confers other benefits, such as enabling them to be prescribed, be advertised and make health claims in line with other medicinal products. An e-cigarette product, e-Voke, was licensed by the MHRA in 2015 but is yet to come to market. E-cigarette use in public places As stated above some people are concerned that the use of e-cigarettes will renormalize smoking, particularly if used in public places. Whilst many e-cigarettes differ in appearance to ordinary cigarettes, when users exhale, they do produce a vapour for which there is no evidence of harm from second-hand inhalation, but could be irritating to non-users in their immediate environment. A number of organisations published a discussion document about whether e-cigarettes should be permitted or prohibited in various premises (ASH 2015) and Public Health England produced guidance including key principles to guide policy making (Public Health England 2016). We have referred to these documents as well as listened to patients view when reaching a decision about e-cigarette use in SLaM. As new evidence emerges we will adapt this policy accordingly. Estates & Facilities e-cigarette alerts Guidance issued by the Department of Health (June 2014) recommended that: 1) all staff should be made aware of possible fire hazards with use/recharging of e-cigarettes; 3) e-cigarettes should not be used in an oxygen rich environment; and 4) safety advice should be given to patients receiving therapies at home.


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Additional guidance issued by the Department of Health (July 2014) suggested that a complete ban on recharging might not be a workable solution. Action required included: 1) reviewing the risk of withdrawing or discouraging re-chargeable e-cigarette use; 2) recording competing risks in the Risk Register; 3) assessing the opportunities for safe, supervised charging of devices by designated staff in designated areas and where this was possible taking several subsequent steps to further reduce risk including only using batteries/chargers that came with the e-cigarette, disconnecting when charge is complete, storing batteries safely etc. E-cigarette use in mental health settings The Care Quality Commission (CQC) recently published guidance on smoke free policies in mental health inpatient services where they clearly distinguished tobacco cigarettes from e-cigarettes. The guidance confirmed that blanket bans on tobacco cigarettes are justified but that blanket bans on e-cigarettes may not be (CQC 2017). The guidance also highlighted the role of e-cigarettes in supporting smoke-free policies and referenced a briefing from the National Centre on Smoking Cessation and Training (NCSCT 2016) The NCSCT briefing recognises that some people find e-cigarettes helpful for quitting, cutting down and/or managing temporary abstinence. Our policy reflects these documents too. References ASH, ASH Wales, RSPH, TSI, UKCTAS< CIEH.( Oct 2015) Will you permit or prohibit electronic cigarette use on your premises? Five questions to ask before you decide. Available at: http://ash.org.uk/information-and-resources/briefings/will-you-permit-or-prohibit-e-cigarette-use-on-your-premises/ Action on Smoking and health (ASH). ( May 2015) Use of electronic cigarettes (vapourisers) among adults in Great Britain. Available at: http://ash.org.uk/information-and-resources/fact-sheets/use-of-electronic-cigarettes-vapourisers-among-adults-in-great-britain/ Beard E, West R, Michie S, Brown J. (2013) Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ 2016;354:i4645. doi: 10.1136/bmj.i4645. Brown J, Beard E, Kotz D, Michie S, West R. (2014) Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addition : 10.1111/add.12623.[Epub ahead of print] Caponetto P et al (2013) . Impact of an electronic cigarette on smoking reduction and cessation in schizophrenic smokers: a prospective 12-month pilot study. Int J Environ Res Public Health. 10:446–618. CQC. Brief guide: smoke free policies in mental health inpatient services( 2017). Available at: https://www.cqc.org.uk/sites/default/files/20170109_briefguide-smokefree.pdf Department of Health. Estates and Facilities Alert (June 2014) Ref: EFA/2014/002. Department of Health. Estates and Facilities Alert Addendum (July 2014). Ref: EFA/2014/002/(NI) Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews (2016), Issue 9. Art. NO: CD010216. DOI:10.1102/14651858. CD010216.pub3. Hickling LM, Perez=Iglesias R, McNeill A, Dawkins L, Moxham J, Ruffell T, Sendt K-V, Mcguire R. (2016). Electronic Cigarettes as a Harm-Reduction Strategy in People with Serious Mental Illness: A Pilot Clinical Trial Poster.

http://ash.org.uk/information-and-resources/fact-sheets/use-of-electronic-cigarettes-vapourisers-among-adults-in-great-britain/

http://ash.org.uk/information-and-resources/fact-sheets/use-of-electronic-cigarettes-vapourisers-among-adults-in-great-britain/


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Hitchman SC, Brose LS, Brown J, Robson D, McNeill A (2015). Associations Between E-Cigarette Type, Frequency of Use, and Quitting Smoking: Findings From a Longitudinal Online Panel Survey in Great Britain. Nicotine Tob Res.17: 1187–1194. McNeill A, Brose L.S., Calder R, Hitchman S.C., Hajek P, McRobbie H (2015). E-cigarettes: and evidence update, Public Health England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf National Centre on Smoking Cessation and Training: (2016) http://www.ncsct.co.uk/usr/pdf/Electronic%20cigarettes.%20A%20briefing%20for%20stop%20smoking%20services.pdf.

Public Health England. E-cigarettes: a developing public health consensus (2016). Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534708/E-cigarettes_joint_consensus_statement_2016.pdf Public Health England (July 2016). Use of e-cigarettes in public places and workplaces Advice to inform evidence-based policy making. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534586/PHE-advice-on-use-of-e-cigarettes-in-public-places-and-workplaces.PDF Royal College of Physicians. Nicotine without smoke. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: Royal College of Physicians, 2016. Available at: https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0. Smoking in pregnancy challenge group (2017). Use of electronic cigarettes in pregnancy: A guide for midwives and other healthcare professionals. http://elearning.ncsct.co.uk/vba_pregnancy-stage_21

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf

http://www.ncsct.co.uk/usr/pdf/Electronic%20cigarettes.%20A%20briefing%20for%20stop%20smoking%20services.pdf

http://www.ncsct.co.uk/usr/pdf/Electronic%20cigarettes.%20A%20briefing%20for%20stop%20smoking%20services.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534708/E-cigarettes_joint_consensus_statement_2016.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534708/E-cigarettes_joint_consensus_statement_2016.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534586/PHE-advice-on-use-of-e-cigarettes-in-public-places-and-workplaces.PDF

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534586/PHE-advice-on-use-of-e-cigarettes-in-public-places-and-workplaces.PDF

https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0


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Appendix 3 - Guidance for staff when supporting e-cigarette users:

• Staff will explain to patients and carers that NRT when given together with intensive behavioural support, are the most effective way to stop smoking. Other licensed stop smoking medicines such as varenicline and bupropion should only be considered following consultation with the chief pharmacist. Staff should only advise on e-cigarette use after patients have considered these treatments:

• Refer to the guidance on e-cigarettes and other harm reduction strategies in Appendix 2 –

Electronic cigarettes, Trust Level 1 e-learning and Level 2 training.

• Support the development of a collaborative plan for the use of e-cigarettes; this should take into account the individuals current risk assessment, current mental state and previous experience of using an e-cigarette.

• Patients who are under 18 or pregnant women will not be allowed to use e-cigarettes on Trust

premises.

• E-cigarettes cannot be prescribed or supplied by staff unless they are licensed by the Medicines & Healthcare products Regulatory Agency (MHRA).

• Disposable e-cigarettes may be the most suitable option for those who present with a high risk

profile, whilst re-chargeable and re-fillable e-cigarettes will be suitable for most patients.

• In the interests of health & safety and to comply with Department of Health guidance patients using a re-chargeable e-cigarette must have an up to date individual risk assessment.

• Some patients risk assessments may dictate that the patient is supervised when re-filling his/her

device, this might be appropriate for example if there is a risk that the patient might add illicit substances to the device.

• Patients will need to purchase their e-cigarettes, in some instances for example for those who are

restricted staff may be able to assist with making these purchases on their behalf.

• 2nd generation E-cigarette use will be permitted on ward and garden areas

• 3rd generation (tank) type E-cigarettes should only be used in garden areas. Please see appendix 4 for distinction of devices

• E-cigarettes should not be used during therapeutic groups and 1:1 sessions.

• E-cigarette users will be required to plan the use of their device with their care team as part of

their care plan (as they would with NRT) and allow staff to check the products that they are using.

• Patients may wish to use their e-cigarette interchangeably with cigarettes (sometimes called dual use). As indicated in Appendix 2, advise patients that replacing some cigarettes with e-cigarettes may confer little benefit. Using NRT products simultaneously with an e-cigarette is unlikely to increase harm.


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• If a patient switches from smoking cigarettes to e-cigarettes this will affect the metabolism of

some prescribed medication. Plasma levels must be monitored and medication regimes adjusted accordingly. This is especially important for those taking clozapine.

• E-cigarette users will be required to store their e-cigarette safely and securely, they should not

share products with others for infection control reasons and should not use them near oxygen/naked flames.

• All used batteries to be disposed of in appropriate grey boxes.


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Appendix 4

The Three generations of E-cigarettes


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Please tick as appropriate

There are no specific training requirements- awareness for relevant staff required, disseminated via appropriate channels

(Do not continue to complete this form-no formal training needs analysis required)

There is specific training requirements for staff groups

(Please complete the remainder of the form-formal training needs analysis required- link with learning and development department.

Appendix 5

Training Needs Analysis

Staff Group if appropriate

Frequency Suggested Delivery Method

(traditional/ face to face / e-

learning/hand-out)

Is this included in Trust wide essential learning

programme for this staff

group

( if yes)

Career Grade Doctor

e-learning

Training Grade Doctor

e-learning

Locum medical staff

e-learning

Registered Nurse

e-learning / Face to Face, Level 1 / Level 2 &

NRT training


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ADDITIONAL INFORMATION FOR CONSIDERATION

Non- registered Nurse / Care Assistant

e-learning

Community Registered Nurse

e-learning

Community Non Registered Nurse / Care Assistant

e-learning

Psychologists / Pharmacists

e-learning

Therapists e-learning

Clinical bank staff regular worker

e-learning

Clinical bank staff infrequent worker

e-learning

Non-clinical service user contact

e-learning

Non-clinical non service user contact

e-learning

Please give any additional information impacting on identified staff group training needs (if applicable)

Please give the source that has informed the training requirement outlined within the policy i.e. National Confidential Inquiry/NICE guidance etc.

Documents

Mersey Care NHS Foundation Trust - Home - …...2017/12/08 · and wellbeing of Trust Service users and staff. All NHS sites will be smoke free healthcare settings the Trust has agreed